This controversial practice complicated by concerns about substance abuse and malpractice represents another behavioral form of depression buy cheap serophene 100 mg line women's health center houston. While the medications have an inherent potential for intoxication and abuse generic serophene 50 mg with visa womens health jacksonville, they often reinforce disability through subtle reinforcement that culminates in the depression of dependency on comfort instead of the satisfaction with overcoming challenges. Olsen and Daumit discuss the problems and expertise required for primary care physicians in ‘Opioid Prescribing for Chronic Nonmalignant Pain in Primary Care: Challenges and Solutions’. Geppert expands these topics in ‘To Help and Not to Harm: Ethical Issues in the Treatment of Chronic Pain in Patients with Substance Use Disorders’. This special population of patients illuminates the issues discussed throughout this volume for all patients with chronic pain. Physicians, psychiatrists in particular, have an obligation to care for the entire patient. Treatment should restore them to healthy individuals, be mindful of the many ways in which they can be harmed, and employ a formulation of their distress, disability, and depression that extends beyond the algorithms, symptom-based, and homogeneous treatment plans of today’s pain centers. The goal of this volume is to focus the discussion about a complicated problem into complementary domains with concrete examples. Hopefully, this will generate interest and some controversy that will take the conversation about and study of these patients to a new level that will improve the practice of medicine and our patients’ outcomes. Treisman, MD, PhD Preface IX Clark MR, Treisman GJ (eds): Pain and Depression. Basel, Karger, 2004, vol 25, pp 1–27 Perspectives on Pain and Depression Michael R. Treismanb aChronic Pain Treatment Programs and bAIDS Psychiatry Services, Department of Psychiatry and Behavioral Sciences, Johns Hopkins Medical Institutions, Baltimore, Md. Chronic pain is often complicated by a variety of psychiatric conditions that make it difficult to engage and treat patients. The patient may be afflicted by the syndrome of an affective disorder, demoralized by the unintended circumstances of their life, unable to meet the demands of stressors because of a lack of inherent capacities, or helplessly trapped by poor choices and repeated unproductive actions. The physician’s interest and the patient’s optimism can be restored and sustained by utilizing a systematic interdisciplinary approach utilizing the four perspectives of diseases, life stories, dimensions, and behaviors to evaluate the patient who is disabled by depression and chronic pain. The design of a comprehensive treatment plan involves the determination of each perspective’s contribution to the patient’s suffering. The process of formulation recognizes that the perspectives are distinct from one another but complementary in illuminating the various reasons for a patient’s suffering. The perspectives offer a recipe for designing a rational treatment plan rather than trying to reduce the individual patient’s complexity into a one-dimensional con- struct. This approach increases the probability of a successful outcome for both patient and physician. Karger AG, Basel pain (pan)– n 1: physical suffering typically from injury or illness. In the most recent review from multiple countries and the WHO, the weighted mean preva- lence of chronic pain was 31% in men, 40% in women, 25% in children up to 18 years old, and 50% in the elderly over 65 years old [Ospina and Harstall, 2002]. During a 2-week period, 13% of the US workforce reported a loss in productivity due to a common pain condition such as headache, back pain, arthritis pain, or other musculoskeletal pain [Stewart et al. In another WHO study of over 25,000 primary care patients in 14 coun- tries, 22% (United States 17%) of patients suffered from pain that was present for most of the time for at least 6 months [Gureje et al. In a study of 6,500 individuals aged 15–74 years in Finland, 14% experienced daily chronic pain that was independently associated with lower self-rated health [Mantyselka et al. A retrospective analysis of 14,000 primary care patients in Sweden found that approximately 30% of patients seeking treatment had some kind of defined pain problem with almost two thirds diagnosed with musculoskeletal pain [Hasselstrom et al. Types of Pain and Depression Pain is a complex experience that is influenced by affective, cognitive, and behavioral factors, and has an extensive neurobiology [Meldrum, 2003; Turk et al. Pain has been defined by the International Association for the Study of Pain as ‘an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage’ [Merskey et al. Chronic pain can be described both by pathophysiological mechanism and anatomical location.

Wilson N (1967) A diagnostic sign in osteochondritis dissecans of ally permanent) dislocation of the patella caused by the knee purchase serophene 25 mg with visa menopause and hair loss. J Bone Joint Surg (Am) 49: 477–80 abnormal traction on the vastus lateralis muscle buy serophene 100mg with amex womens health johnson city tn. Wirth T, Rauch G, Schuler P, Griss P (1991) Das autologe Knorpel- ▬ Iatrogenic dislocation of the patella: Medial subluxation Knochen-Transplantat zur Therapie der Osteochondrosis disse- cans des Kniegelenkes. Z Orthop 129: 80–4 or dislocation of the patella after surgery to correct a lateral dislocation of the patella. A proportionate level of trauma is needed to produce an acute dislocation of the patella. The injury usually Classification occurs when the knee is in a position of flexion, valgus We distinguish between the following: and external rotation. This is the same mechanism that ▬ Acute traumatic dislocation of the patella: Lateral most commonly leads to rupture of the anterior cruciate dislocation of the patella caused by proportionate ligament in adults. Other concomitant injuries are dislocation of the patella in the presence of predis- also often observed, for example disruption of the medial posing factors. Usually progresses to the recurrent retinacula and shear fractures of the medial patellar facet form. Acute traumatic dislocation ▬ Recurrent dislocation of the patella: Repeatedly occur- of the patella without any predisposing factors is rare in ring lateral dislocations of the patella in the presence children and adolescents. Acute constitutional dislocation of the patella This injury is observed much more frequently in chil- dren and adolescents than acute traumatic dislocation. In contrast with the latter, the trauma of the triggering accident is not proportionate, few concomitant injuries are observed and predisposing factors are present (these are described in detail for the recurrent form). The acute predispositional form almost always progresses to a recur- rent form. Recurrent dislocations of the patella In this common condition, recurrent lateral dislocations of the patella occur with increasing frequency. The dis- locations are promoted by the following predisposing factors: ▬ General ligamentous laxity: Most patients show signs of a general weakness of the ligaments. Typically, recurrent dislocations of the patella are also common in hereditary disorders associated with a diminished 301 3 3. Ehlers-Danlos syndrome, arachnodactyly or Marfan syndrome, osteogenesis imperfecta, Turner syndrome, Down syndrome, Kabuki syndrome) (see also chapter 4. A fairly recent MRI-based study has shown the regular presence of fibrosis of the vastus lateralis muscle in patients with habitual dislocation of the patella. Flattening of the lateral fem- oral condyle and a reduced indentation of the patel- lofemoral groove will promote dislocation. Tearing of the medial ligaments and shortening of the lateral liga- mentous apparatus will promote dislocation. Determination of the Q-angle: The angle between the tella, the patella will show a delay in sliding into the axes of the quadriceps and patellar tendons. An angle of more than patellofemoral groove during increasing flexion and 15° is considered to be pathological, although the measurement is thus make a dislocation more likely. However, CT measure- ments have shown that this angle was not increased, but rather reduced, in a fairly large sample of patients with patellar dislocation [21, 24]. This was partly due to the fact that the patella in these patients was in a more lateral position than normal. Additionally, increased rotation between the femur and tibia is a typical feature of patients with recurrent dislocation of the patella. In most cases it is not one individual factor that leads to the establishment of recurrent dislocation of the patella, but rather a combination of various elements. Habitual dislocation of the patella In this form of the condition the patient can dislocate the patella at will by exerting lateral traction on the vastus lateralis muscle. The kneecap slides to the side during increasing flexion and then reduces itself again on exten- sion. The predisposing factors are even more pronounced compared to the recurrent form. Nor is it possible to make a clear distinction between habitual and congenital The patella is a like a pulley. The incident is often described as »giv- The patella is permanently dislocated and is often (par- ing way«, »locking up«, and occasionally as »going out«.

With the patient still seated order serophene 50 mg fast delivery menstrual hormone chart, test for stability of the medial collateral ligament (MCL) cheap 50mg serophene with visa women's health clinic unionville. Next, secure the patient’s ankle in one hand and cup the patient’s knee with the other hand so that your thenar eminence is against the patient’s fibular head. Place a firm valgus stress on the patient’s knee by push- ing medially against the patient’s knee and pulling laterally against the patient’s ankle—this maneuver is performed in an attempt to open the medial side of his knee (Photo 5). If there is an MCL injury, there will be medial joint-line gapping that you will appreciate with the fingers that are cupped around the patient’s knee. When the valgus stress on the patient’s leg is relieved, the patient’s knee may be felt to “clunk” back together if there is an MCL tear. To test for a lateral collateral ligament (LCL) tear, apply a varus stress to the patient’s joint by pushing the patient’s ankle medially while pulling the patient’s knee laterally. Remember to keep your hand cupped around the lateral aspect of the joint in order to appreciate gap- ping, if present (Photo 6). Next, have the patient lie in the supine position while you check for an effusion. Look for a large effusion by pushing the patient’s patella superiorly and then quickly releasing it. If there is a large amount of fluid, the fluid will redistribute and push the patella into its former position. Knee Pain 99 you may need to milk the fluid from the suprapatellar pouch and the lat- eral side of the knee over to the medial side of the knee. Then, you would release the fluid and tap the medial aspect of the knee. In the next few seconds, if an effusion is present, then the fluid will redistribute laterally and a fullness will develop on the lateral side of the knee. The Lachman test is performed by flexing the patient’s knee to 20° and sta- bilizing the patient’s femur with one hand and pulling the tibia toward you with the other hand. This is important because a few degrees of anterior glide of the tibia on the femur may be normal. The anterior drawer test is a similar test that should also be per- formed to evaluate for an ACL injury. In this test, the patient’s knee is flexed to 90° with the feet flat on the table. The examiner sits on the patient’s foot to stabilize it, and with the examiner’s hands cupped around the back of the patient’s upper calf, the tibia is pulled toward the examiner (Photo 7). If the tibia slides forward from under the femur more than a few degrees, there may be a tear in the ACL. If the patient has a positive anterior drawer sign or Lachman test, repeat the maneuver with the patient’s leg in external and internal rota- tion. Repeating the maneuver with the leg in external rotation should tighten the posteromedial portion of the capsule. If the patient’s tibia glides forward as much as it did with the leg in the neutral position, an MCL tear may be accompanying the potential ACL tear. Repeating the test with the leg in internal rotation tightens the posterolateral capsule. If the patient’s tibia again glides forward as much as it did with the leg in the neutral position, an LCL tear may be accompanying the poten- tial ACL tear. To test for a posterior cruciate ligament (PCL) tear, the examiner stays seated on the patient’s foot as for the anterior drawer test. However, instead of pulling the patient’s tibia toward the examiner, the tibia is pushed posteriorly (Photo 8). If the patient’s tibia glides posteriorly on the femur, it is likely torn, although the PCL is rarely torn. In this sign, the patient’s hip is flexed to 45° and the knee is flexed to 90°. The examiner supports the limb by holding the patient’s ankle (Photo 9).

Puylaert D order serophene 50mg mastercard menstrual disorders symptoms, Dimeglio A discount 25mg serophene amex womens health exercise equipment, Bentahar T (2004) Staging puberty in slipped 20. Hoaglund F, Steinbach L (2001) Primary osteoarthritis of the hip: capital femoral epiphysis. Imhäuser G (1954) Die operative Behandlung der pathologischen epiphysis. Jerre R, Billing L, Hansson G, Wallin J (1994) The contralateral hip disturbances of the proximal femur after pinning of juvenile slipped in patients primarily treated for unilateral slipped upper femoral capital femoral epiphysis. Segal LS, Weitzel PP, Davidson RS (1996) Valgus slipped capital femo- 563–7 ral epiphysis. Kallio PE, Paterson DC, Foster BK, Lequesne GW (1993) Classification 47. Southwick WO (1967) Osteotomy through the lesser trochanter in slipped capital femoral epiphysis. Vrettos BC, Hoffman EB (1993) Chondrolysis in slipped upper femo- study after corrective Imhauser osteotomy for severe slipped capital ral epiphysis. Yngve DA, Moulton DL, Burke Evans E (2005) Valgus slipped capital tribution of slipped capital femoral epiphysis in Connecticut and femoral epiphysis. If a teratological dislocation is suspected, an x-ray and MRI scan are indicated as de- Classification formities of the femoral head (e. The localized disorders include: ▬ teratological dislocation of the hip, Treatment ▬ proximal femoral focal deficiency, The treatment of teratological dislocations is essentially ▬ coxa vara and femoral neck pseudarthrosis. An open Typical changes in this area are found in association with reduction is usually unavoidable, and deformities of the the following systemic illnesses: soft tissues and the bony and cartilaginous skeleton also ▬ multiple epiphyseal dysplasia, have to be taken into account (see chapter 3. The risk of redislocation is much ▬ dysplasia epiphysealis hemimelia, greater than with dysplasia-related dislocation. If a deformity or defect of the femur exists, the proximal part is always affected as well, hence the description of These diseases are discussed in chapter 4. At this point ▬ proximal femoral focal deficiency (abbreviated to we shall restrict ourselves to the specific changes in those PFFD) or congenital femoral deficiency (CFD) forms of multiple epiphyseal dysplasia that are manifested in the hip only. Classification Various classifications have been proposed for proximal 3. The classification Teratological hip dislocation most commonly used is that of Aitken (⊡ Fig. This is a purely radiological classification and thus in- > Definition complete. The condition frequently has to be reclas- Dislocation of one, or usually both, hips at birth as a sified during the course of growth. A comprehensive result of malformations rather than immaturity of the classification of congenital anomalies of the femur has joints, and associated with other deformities. More Occurrence recently Paley proposed a classification with 3 types Since teratological hip dislocation is not a systemic illness (⊡ Table 3. In particular, these techniques ring deformities are: can show whether a femoral head is present or not, a find- Torticollis, plagiocephaly (32%), arthrogryposis, ing that is important for correct classification. Larsen syndrome, general ligament laxity, flat feet, club feet, proximal femoral focal deficiency, congenital Occurrence knee dislocation, pyloric stenosis, renal agenesis and or- The incidence of proximal femoral focal deficiency cal- chidocele. Compared to dysplasia-related hip dislocation, culated in an epidemiological study was found to be 2 teratological dislocation of the hip is extremely rare. If all femoral anomalies are taken into account, the frequency is undoubtedly much Diagnosis greater since mild forms of femoral hypoplasia in par-! If an abnormality of any kind exists at birth, an ticular are very numerous and usually not yet diagnosed ultrasound scan of the hips is invariably indicated. Classification of a proximal focal femoral deficiency (PFFD) (I–IX) accord- ing to Pappas (see text) ⊡ Table 3. Classification of congenital femoral anomalies of the femur after Pappas deficiency (CFD) after Paley Class Characteristics Type I Complete absence of the femur 1 Intact femur with mobile hip and knee a) normal ossification of proximal femur II Proximal femoral deficiency combined with lesion of b) delayed ossification of proximal femur the pelvis 2 Mobile pseudarthrosis (hip not fully formed, a false III Proximal femoral deficiency without bone connection joint) with mobile knee between the femoral shaft and head a) femoral head mobile in acetabulum IV Proximal femoral deficiency with poorly organized b) femoral head absent or stiff in acetabulum fibro-osseous connection between the femoral shaft 3 Diaphyseal deficiency of femur (femur does not reach and head the acetabulum) V Femoral deficiency in the middle of the shaft with a) knee motion > 45° hypoplastic proximal or distal bony development b) knee motion < 45° VI Distal femoral deficiency VII Hypoplastic femur with coxa vara and sclerosis of diaphysis VIII Hypoplastic femur with coxa valga IX Hypoplastic femur with normal proportions 227 3 3.